Long-term clinical, functional and radiological outcome 21 years after posterior or posterolateral fusion in childhood and adolescence isthmic spondylolisthesis

Long-term radiological studies have shown that a high rate of fusion can be achieved with posterolateral spondylodesis. Radiological findings, however, do not always correlate with patient satisfaction and outcome. No studies have been conducted on the long-term results of functional outcome, including spinal mobility and trunk strength measurements, after operative treatment of spondylolysis and spondylolisthesis, as compared with the reference population. Of 129 consecutive patients with isthmic spondylolisthesis operated on with spondylodesis between 1977 and 1987, 107 (83%) participated in the study. Posterior spondylodesis was performed in 29 (27%) patients and posterolateral spondylodesis in 78 (73%) patients. The average follow-up time was 20.9 years (range 15.1–26.2 years). Radiographs obtained preoperatively and at the 2-year and final follow-ups were assessed for quality of the fusion and degenerative changes. Outcome was assessed at the last follow-up by physical examination, spinal mobility and non-dynamometric trunk strength measurements, and calculation of Oswestry disability index (ODI) scores. The fusion rate was 66% after posterior fusion and 83% after posterolateral fusion. Degenerative changes in the lumbar intervertebral discs above the fusion level were noted in 13 (12%) patients. At the final follow-up 14% of patients reported back pain often or very often. The mean ODI score was 7.6 (0–68). Moderate disability was found in 6% of patients and severe disability in 1%; one patient was crippled. No correlation was found between disc degeneration or solidity of the fusion and the ODI score. Non-dynamometric trunk strength measurements corresponded with the reference values. Lumbar flexion, but not extension, was diminished when compared with that of the reference population. The overall long-term clinical outcome is good in patients with spondylolysis and spondylolisthesis operated on with posterior or posterolateral fusion. The clinical and radiological outcomes do not, however, appear to correlate with each other. Lumbar flexion is diminished, but the patients perform, on average, as well as the general population in non-dynamometric trunk strength measurements.     

The impact of legislative versus non-legislative quality policy in health care: a comparison between two countries

An important aim of the government's quality policy is to stimulate quality management (QM) in health care organizations. The relationship between the government's quality policy and QM in health care organizations is unknown. This article explores that relationship by comparing two countries with different quality policies, The Netherlands and Finland. In The Netherlands QM is required by law and health care is organized at national level. In Finland, QM is not required by law and the responsibilities for organizing health care are delegated to the municipalities. The question is whether or not these differences in national policy are reflected in the extent and effectiveness of QM in health care organizations in the two countries. A cross sectional survey was conducted in late 1999. Data about QM in both countries were gathered by questionnaire. The subsectors involved were hospitals, care for the disabled and care for the elderly. A total of 1172 health care organizations participated in the study (response rate 64%). The results show that-in keeping with our hypothesis-slightly more QM-activities and more patient participation were found in Dutch health care organizations compared with the Finnish ones. However, contrary to our expectations, the Finnish organizations reported more perceived effects of their QM-activities. Further analyses showed that some QM-activities are more closely related to the effectiveness of QM than others. In particular, cyclic quality improvement procedures, human resource management and the flexible attitude of employees showed the strongest relationship with the perceived effects of QM. The difference between the national approach in The Netherlands and the decentralized approach in Finland did not, as we had assumed, result in more regional variation in QM in Finland. CONCLUSIONS: a government's quality policy may have some influence on the extent of QM in health care organizations. However, more QM-activities do not necessarily imply more effects. RECOMMENDATIONS: since QM-activities differ in the degree to which they bring about changes and improvements in care, it is recommended that policy makers promote those QM-activities, which are the most potent, in order to improve the quality of care.     

Collagen formation in extracellular matrix of transplants of human transformed keratinocyte cell lines

BACKGROUND, MATERIALS AND METHODS: The role of epithelial cell growth and neoplastic transformation on collagen formation and deposition in the extracellular matrix (ECM) was analyzed by culturing immortalized human epidermal cell lines and Ras-transformed benign and malignant clones on collagen gels as transplants. The lesions were analyzed for extent of growth and morphology of epithelial and mesenchymal components as well as synthesis and deposition of different collagens. RESULTS: Immortalized cell lines required up to 5 weeks of growth for a well-organized mesenchyme to develop; transplants of Ras-transformed benign clones needed 3 weeks and transplants of highly malignant clones only 2 weeks to form an organized stroma. In transplants of immortalized cells after 2 weeks of growth newly-synthesized collagen type I and type III were deposited in the mesenchyme adjacent to the muscle, forming a mature ECM, while ECM was absent adjacent to growing, differentiated, immortalized cells. In transplants of Ras-transformed benign clones the subepithelial ECM was immature at day 14, but it was forming fibers at the same time in transplants of malignant clones. These were seen as thin irregular fibers in immunohistochemistry, ultimately organized into fibrillar structures in similar locations to active synthesis detected by in situ hybridization. Depositions of crosslinked mature type I collagen occurred later in similar locations. Type III collagen synthesis and deposition was most prominent in transplants of malignant cell clones, with degradation and destruction of the extracellular matrix around invading islets of malignant cells. CONCLUSION: The development of mesenchyme was directly related to duration of growth of transplants and degree of malignancy; mesenchyme organization was inversely related to differentiation of the epithelial cells. The results showed the usefulness of the transplant model in studies on cell and tissue growth and organization.     

The Use of MCDA in HTA: Great Potential,but More Effort Needed

The potential for multi-criteria decision analysis (MCDA) to support health technology assessment (HTA) has been much discussed, and various HTA agencies are piloting or applying MCDA. Alongside these developments, good practice guidelines for the application of MCDA in health care have been developed. An assessment of current applications of MCDA to HTA in light of good practice guidelines reveals, however, that many have methodologic flaws that undermine their usefulness. Three challenges are considered: the use of additive models, a lack of connection between criteria scales and weights, and the use of MCDA in economic evaluation. More attention needs to be paid to MCDA good practice by researchers, journal editors, and decision makers and further methodologic developments are required if MCDA is to achieve its potential to support HTA.     

Customer Satisfaction Measurement in Emergency Medical Services

Objectives: The annual patient volume in emergency medical services (EMS) systems is high worldwide. However, there are no comprehensive studies on customer satisfaction for EMS. The authors report how a customer satisfaction survey on EMS patients was conducted, the results, and the possible causes for dissatisfaction. Methods: Two prospective customer satisfactions surveys were conducted in an urban EMS system. Consecutive patients treated by EMS received a postal questionnaire approximately two weeks after service. Satisfaction was measured in a scale from 1 (very poor) to 5 (excellent). Neither EMS personnel nor patients were made aware prospectively that patient satisfaction would be measured. Results: Response rates to the surveys were 36.8% (432/1,175) in 2000 and 40.0% (464/1,150) in 2002. The mean general grades for the service were 4.6 and 4.5, respectively. Patients reported the highest degree of dissatisfaction when they were not taken to their hospital of choice, when they perceived that the paramedics were not able to meet their needs, and when paramedics did not introduce themselves or communicate directly with the patient's relatives. In high-volume calls (i.e., frequent chief complaints), the general satisfaction was highest in patients with arrhythmias, breathing difficulties, and hypoglycemia. Patients with drug overdose included the highest proportion of unsatisfied patients. None of the background variables (e.g., gender, transport decision, working shift) was statistically related to general patient satisfaction. Conclusions: This study shows that customer satisfaction surveys can be successfully conducted for EMS. EMS systems should consider routinely using customer satisfaction surveys as a tool for quality measurement and improvement.     

Lumbar paraspinal and biceps brachii muscle function and movement perception in lumbar spinal stenosis

Introduction

Impaired muscle function and lumbar proprioception have been observed in lumbar spinal stenosis (LSS) but those have not been studied in LSS patients with age-matched controls. We assessed lumbar movement perception and paraspinal and biceps brachii (BB) muscle responses during sudden upper limb loading in age-matched healthy subjects and patients with LSS.

Methods

The study included 30 patients selected for an operation due to LSS and 30 age-matched controls without chronic back pain. The paraspinal and BB muscle responses for upper limb loading during unexpected and expected conditions were measured by surface EMG. The ability to sense lumbar rotation was assessed in a previously validated motorized trunk rotation unit in a seated position. Pain, disability and depression scores were recorded.

Results

Patients had poorer lumbar perception (mean difference 2.3 ± 0.6°, P < 0.001) and longer paraspinal muscle response latencies [mean difference 4.6 ± 0.6 ms (P = 0.033)] than age-matched healthy controls. Anticipation increased paraspinal and BB muscle activation prior to the load perturbation (P < 0.001) but less in LSS patients than in controls [9 vs. 30 %, P = 0.016 (paraspinals); 68 vs. 118 %, P = 0.047 (BB)].

Conclusions

The observed impairments in lumbar proprioception and activation of paraspinal and upper limb muscles indicate an extensive loss of both sensory and motor functions in LSS. The main new finding was decreased anticipatory muscle activation during expected upper limb loading reflecting involvement of central movement control mechanisms.     

New mini-extracorporeal circulation system (ECC.O) is a safe technique in coronary surgery

Objectives. Cardiopulmonary bypass (CPB) is known to cause the systemic inflammatory reaction after cardiac surgery. New coated and closed loop circuit systems may reduce this inflammation response and improve the surgical outcome. This study was designed to evaluate the safety and efficacy of the mini-extracorporeal circulation system (ECC.O) in CABG patients. Design. Forty patients undergoing elective coronary surgery were randomized into two groups, the ECC.O group and the standard CPB group. Routine hemodynamic monitoring and biochemical measurements were registered according to the hospital practice. Results. The clinical outcome of the patients was similar in both groups. There were no significant differences between the groups in the duration of intubation following surgery, the length of intensive care unit-stay or the total hospital stay. The haemoglobin level was significantly higher (p=0.0069) during and after the perfusion in the ECC.O group. Conclusions. The ECC.O system can be safely used in CABG patients and it maintains haemoglobin level better than conventional CPB.     

Dietary zinc intake and the risk of depression in middle-aged men: A 20-year prospective follow-up study

Background

Zinc is an immunomodulatory trace element suggested to be beneficial in the augmentation of antidepressant therapy. Cross-sectional studies have also suggested an association between low dietary zinc and depression. This study examined the association between dietary zinc intake and depression in a prospective setting in initially depression-free men during a 20-year follow-up.

Methods

The study formed a part of the population-based Kuopio Ischemic Heart Disease Risk Factor (KIHD) Study, and comprised 2317 Finnish men aged 42–61 years. Zinc intake was assessed at baseline by a 4-d food record. Baseline depression severity was recorded with the Human Population Laboratory Depression Scale. In the prospective setting, depression was defined as having received a hospital discharge diagnosis of unipolar depressive disorder. Individuals who at baseline had elevated depressive symptoms were excluded (n=283).

Results

Altogether, 60 (2.7%) individuals received a hospital discharge diagnosis of depression during the 20-year follow-up. In Cox regression analysis adjusted for age, baseline depression severity, smoking, alcohol use, physical exercise and the use of dietary supplements, belonging to the lowest tertile of energy-adjusted zinc intake was not associated with an increased depression risk (RR 1.06, 95% CI 0.59–1.90).

Limitations

These observations may not be generalizable to women, or to individuals with a depression level not warranting hospitalization.

Conclusions

Our findings suggest that a low dietary zinc intake may not longitudinally precede depression in men. Dietary zinc intake may not have relevance for the prevention of depression in middle-aged men with a sufficient dietary zinc intake.     

Changes in prevalence and correlates of alcohol-use disorders in Finland in an 11-year follow-up

Abstract

Aims: This study aimed to examine changes in prevalence and correlates of alcohol-use disorders (AUD) between 2000 and 2011. We also explored the impact of using multiple imputation on prevalence estimates, to address survey nonresponse.

Methods: The study used a Finnish nationally representative survey of adults aged 30 years and older in 2000 and in 2011. The Munich Composite International Diagnostic Interview (M-CIDI) was used to diagnose AUD in 6005 persons in 2000 (response rate 75%) and 4381 in 2011 (response rate 55%). Multiple imputation using sociodemographic, health, and registry-linked data on mental health hospitalizations was compared with weights to account for nonresponse.

Results: Prevalence of 12-month AUD in Finland decreased from 4.6% (95% CI 4.0–5.1) in 2000 to 2.0% in 2011 (95% CI 1.6–2.4). Lifetime AUD prevalence decreased from 10.8% (95% CI 9.9–11.6) to 7.5% (CI 95% 6.8–8.3) from 2000 to 2011. The reduction was observed for people aged 30–64 years. At both time points, AUD prevalence was higher among individuals aged 30–64, men and those unmarried, widowed or divorced. The observed prevalence changes can be partly attributed to reporting and selection bias. The latter was addressed by multiple imputation.

Conclusions: Alcohol use disorders appear to have decreased in Finland from 2000 to 2011, especially for the 30–64 years age group. Males, younger adults and those unmarried, widowed or divorced had a higher risk of AUD.